Are Case Reports still Relevant in the Era of Evidence-based Medicine?

INTRODUCTION Over the years, the rise of evidence-based medicine (EBM) based on robust data has reshaped clinical practice at an accelerating pace. Within the hierarchy of evidence, case reports traditionally occupy the lowest tier, when compared to randomized controlled trials and meta-analyses, which occupy the top of the pyramid of EBM. This has led to a gradual decline in their perceived academic value. This review revisits their unique contributions and continuing relevance to vascular surgery. Advocates of EBM contend that case reports, due to their anecdotal nature, constitute a lower tier of evidence than systematic reviews and randomized controlled trials. HISTORICAL PERSPECTIVE AND EVOLUTION OF CASE REPORTS However, it should not be forgotten that many innovations in medicine started with a single case, in which an astute surgeon or physician with an analytical mind conceived a novel idea that eventually evolved through clinical trials into a standard of practice over many years. Historically, many inventions in vascular surgery, from Andreas Grüntzig’s first human percutaneous transluminal angioplasty to Juan Parodi’s innovation of endovascular aneurysm repair, were initially reported in case reports, which eventually laid the foundation for an endovascular revolution in medicine.1,2 Even in the current era, where large datasets dominate, the first indication of an emerging trend often begins with an insightful surgeon documenting an unusual presentation or an innovative surgical or endovascular technique, as a case report, which may be the first signal of future trends in vascular surgery. CLINICAL RELEVANCE OF CASE REPORTS IN VASCULAR SURGERY In contrast to other specialties, the complexity of the vascular system often leads to the diagnosis of complex vascular pathologies, with atypical presentation. In the era of endovascular interventions, novel techniques, unexpected procedural complications, and innovative salvage techniques are increasingly being encountered. When meticulously documented, these unique experiences offer valuable insights that are directly applicable to the operating room or endovascular suite. Aligned with this viewpoint, many journals have introduced dedicated companion journals, such as this one (IJVES Clini), specifically for publishing case reports. Similarly, other leading vascular surgery journals, including the Journal of Vascular Surgery (JVS) and the European Journal of Vascular and Endovascular Surgery (EJVES), have also developed companion platforms, namely JVS-Cases, Innovations and Techniques and EJVES Vascular Forum, to showcase case reports, technical notes, and innovative clinical experiences. REPORTING STANDARDS AND GUIDELINES Similar to the Strengthening the Reporting of Observational Studies in Epidemiology Statement and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement guidelines for the preparation of cohort, case–control, cross-sectional studies, and meta-analyses, there are CARE Guidelines for the proper reporting of case reports, which are endorsed by many journals.3,4 The CARE guidelines (for CAseREports) were developed by an international group of experts and published in 2017, to support uniformity and increase transparency, and usefulness of case reports.5 The CARE guidelines detail a 13-point checklist for authors from the title, keywords, and abstract, to the discussion, patient perspective, and informed consent6 Table 1. Some key highlights that are different from other journal manuscripts are a brief summarization of the case’s uniqueness and one or two key takeaways for readers. A timeline of historical and contemporary events should be systematically organized and presented as a figure or table. It is also recommended to include the patient’s perspective on the treatment received, along with confirmation of informed consent for publication, which should be provided to the journal upon request.Table 1: Recommended structure for case reports (adapted from the CARE CAse REport Guidelines)CONTEMPORARY RELEVANCE OF CASE REPORTS Case reports are often a stepping stone for young medical graduates and residents into medical publishing. They not only introduce the fundamentals of scientific writing but also foster inquisitiveness by sharpening observational skills and acquiring clinical competencies in medicine and surgery.7 Werner Forssmann, a German medical student, serves as a historical example of pioneering advancements in medical procedures. At the age of 25 years, Forssmann conducted a groundbreaking experiment by threading a ureteral catheter through a vein in his arm to reach the right atrium, establishing the basis for modern cardiac catheterization techniques.8 Although he initially encountered criticism and professional obstacles due to his self-experimentation, his findings were eventually documented in a case report, leading to his receipt of the Nobel Prize in Physiology in 1956.9 Well-written case reports often lay the foundation for evidence generation in the management of rare diseases, vascular anomalies, rare presentations, and rare complications of interventions in vascular surgery, where a prospective randomized study may not be possible.10 In the current era of artificial intelligence (AI)-assisted medical publishing, most academic journals permit the use of AI for manuscript composition, language refinement, and data analysis, provided appropriate disclosure is made. Consequently, seemingly robust observational studies, including datasets, may be generated without adequate human oversight. However, as AI-generated images and figures are generally not accepted, and as high-quality imaging is a fundamental component of most case reports, their originality is less likely to be compromised.11 LIMITATIONS AND PUBLICATION CHALLENGES Case reports are inherently limited by their small sample size and retrospective design, which may result in missing data that are not documented in medical records.10 In addition, these reports often reflect the singular experiences of authors at their respective centers and within specific populations, raising concerns about their generalizability to broader patient populations. Furthermore, there is a potential for selection bias, as cases with favorable outcomes are more likely to be reported, while those with unfavorable outcomes – which are equally critical for clinical learning – are frequently underreported.12 Another important concern from the authors’ perspective is the limited availability of publication avenues for case reports. Many indexed journals have high rejection rates for such submissions, whereas others that accept case reports may not offer indexing advantages. In addition, several journals impose substantial article processing charges for case reports, which can pose a significant barrier to publication for trainees and authors from low- and middle-income countries, who frequently rely on case reports as an initial entry point into medical publishing.13 CONCLUSION Despite their perceived limitations, case reports remain highly relevant in the era of AI and EBM, as they continue to provide novel and timely insights into the medical practice. This is particularly relevant in the domain of vascular and endovascular surgery, where rapidly advancing techniques and devices necessitate continuous learning. While publications such as case reports enable vascular surgeons to refine technical skills, evidence from larger observational studies and clinical trials provides a better framework for evidence-based practice. In addition to introducing trainees to research and academic publication, case reports help cultivate keen observational skills and emphasize meticulous documentation of clinical practice. The reporting of complications and bailouts further contributes to improved patient outcomes by increasing awareness of uncommon clinical scenarios in vascular surgery. In this rapidly evolving context of AI-assisted research, the authenticity and clinical relevance of well-documented case reports remain invaluable. Journals such as this should continue to support their publication through fair and accessible policies and encourage vascular surgeons to actively report and publish their experiences, thereby contributing to the progress in medicine.